Synopsis On 09 April 1994, the tanker DIAMOND STAR was en route from Saint-Romuald, Quebec, to Morrisburg, Ontario, with a full load of petroleum products. A few minutes after the pilot change at Trois-Rivires, Quebec, the ship's crew saw the north pier of the Laviolette bridge about 150 metres dead ahead of the vessel. An emergency manoeuvre was made and the collision was averted at the last moment. The Board determined that the pilot's health and state of mind when he took the conduct of the DIAMOND STAR very likely led to the near-collision. Contributing factors to this occurrence were the adaptation of the eyes to darkness and the low brightness level of the navigation lights on the bridge. Ce rapport est galement disponible en franais. 1.0 Factual Information 1.1 Particulars of the Vessel 1.1.1 Description of the Vessel The DIAMOND STAR is a double-hulled tanker with the accommodation located aft. There is no superstructure obstructing the view from the wheel-house. The navigation bridge has a central integrated navigation console that the officer of the watch (OOW) can operate unassisted. 1.2 History of the Voyage The DIAMOND STAR departed Saint-Romuald at 1612(3), 09 April 1994, bound for Morrisburg, with a cargo of 10,000 m3 of diesel oil. The voyage from Saint-Romuald to Trois-Rivires was uneventful. The pilot change, made about 1.5 miles downstream from the Laviolette bridge, was normal. Immediately after the pilot change, full-ahead power was resumed and the course was altered to follow the centre line of the channel under the Laviolette bridge. The pilot took up a position at the workstation to the right of the central console. A few minutes later, at about 2220, the OOW and master saw the base of the north pier of the main span of the bridge close to, dead ahead of the vessel. The master ordered hard-a-port helm. The pilot then immediately ordered hard-a-starboard helm. The master repeated his order and the helm was turned hard-a-port. The vessel turned to port, missed the pier, and passed under the main span without touching the bridge substructure. After the vessel cleared the bridge, the master noticed that the pilot smelled of alcohol. He ordered him to anchor the vessel for the night. The pilot was relieved from duty and, at approximately 0145 the next morning, another pilot was dispatched aboard the vessel. At a special meeting of the members of the Laurentian Pilotage Authority (LPA) on 12 April 1994, it was resolved, in view of the report of the master of the DIAMOND STAR and the complaint filed by the vessel owners, Rigel Chem Elbe Ltd., to suspend the pilot's licence for 15 days beginning on 11 April 1994. It was further resolved to take measures to suspend the pilot's licence for an indefinite period. These measures were implemented. 1.3 Injuries to Persons No one was injured as a result of the occurrence. 1.4 Damage There was no damage to the vessel, and no environmental damage resulted from the occurrence. 1.5 Certification 1.5.1 Vessel The vessel was certificated for the voyage being undertaken in accordance with existing regulations. 1.5.2 Personnel The master held a Canadian certificate as Master, Foreign-going, issued on 25 January 1980. The OOW held a Canadian Watchkeeping Mate's Certificate issued on 07 March 1990. The pilot held a Canadian pilotage licence since 03 May 1972. He was issued a class A licence on 03 May 1977. 1.6 Personnel History 1.6.1 Master The master had been sailing for about 30 years. He had nine years' experience as master. He also had nine years' experience on the St. Lawrence River. This was his second two-month tour of duty on the DIAMOND STAR. 1.6.2 Officer of the Watch (OOW) The OOW had been sailing for about 11 years, the last 3 as navigation officer. He had been on the DIAMOND STAR for about two months. 1.6.3 Pilot The pilot had been sailing for 31 years. He had piloted in the No. 1 district of the LPA since 1972. This was his first assignment on this vessel. On 08 April 1994, he was assigned to a vessel downbound on the St. Lawrence River. The passage took about five hours. He disembarked at Trois-Rivires around 1520 and stayed there until his next assignment. The pilot stated that he slept normally on the night of 08/09 April and from 1900 to 2000 that day before going aboard the DIAMOND STAR. 1.7 Pilotage Act and Regulations Section 25(3) of the Pilotage Act prohibits pilots from having the conduct of a ship when they know of any physical or mental disability that prevents them from performing their duties or when their ability is impaired by alcohol or a drug (see Appendix C). According to the provisions of the Act, non-compliance may result in disciplinary measures up to and including cancellation of the pilot's pilotage licence. 1.8 Medical Information Concerning the Pilot The investigation into the medical history of the pilot involved in the near-collision indicated that he had a severe alcohol addiction problem and related behavioural problems. His problems with alcohol date back some 24 years. It was reported that his alcohol addiction sometimes affected his attitude and that his reactions were at times unusual. The diagnoses by the physicians who treated the pilot in recent years mentioned organic complaints caused by alcohol. The pilot had been hospitalized in Montreal from 01 to 10 October 1992 to undergo treatment for his alcohol addiction. On 29 June 1993, at his routine medical examination required by the LPA, the pilot stated that he had received treatment for alcohol addiction in 1992 and was currently totally abstaining. On 22 July 1993, the pilot was admitted to an alcoholism treatment facility for detoxification and rehabilitation. He left the facility the same day. On 11 March 1994, the pilot consulted a physician to tell him that he wanted to undergo treatment for alcohol addiction. He was admitted to an alcoholism treatment facility a month and a half later, that is, 17 days after the occurrence at the Laviolette bridge. 1.9 Medical Examinations for Pilots The General Pilotage Regulations require that all licensed pilots and holders of a pilotage certificate undergo a medical examination at least once every three years. The physician appointed by the pilotage authority must send to the authority a written report of the examination results which clearly indicates if the person examined is medically fit or unfit to carry out pilotage duties. The pilot of the DIAMOND STAR had the required medical examination on 29 June 1993. Responding to the questionnaire contained in the medical report, the pilot stated that, in 1992, he had received alcohol addiction treatment in a hospital and was currently totally abstaining. The LPA received this report which stated that the pilot was fit for duty (apte exercer les fonctions de pilote). However, the LPA took no steps to follow up on the pilot's report and to check on his continued abstinence, nor to encourage him to continue with rehabilitation. 1.10 Assistance Program for Pilots The investigation revealed that the acts and regulations relating to pilotage authorities and corporations in Canada do not provide for programs of prevention, diagnosis or assistance for pilots with drug or alcohol addiction problems. The group insurance plan for the members and employees of the corporation, which covers the pilot of the DIAMOND STAR, does not pay benefits to a pilot whose disability is caused by addiction to alcohol or drugs. However, if the insured receives medical care or treatment from a specialized organization or institution, benefits are provided, but will not continue during the rehabilitation period following treatment. Furthermore, the pilot cannot receive benefits if his licence has been suspended. 1.11 Proficiency Checks for Pilots In order to be issued a pilotage licence for a given pilotage district, a ship's officer must receive at least two years' training followed by written and oral examinations. Successful candidates then receive a class C pilotage licence. After gaining the required experience, the pilot is issued a class B licence, and later a class A licence. There is no regulatory requirement for holders of class C pilotage licences to upgrade their technical skills, and no further proficiency checks are administered. 1.12 Weather Information At the time of the occurrence, the winds were light and visibility was good. 1.13 Ergonomics on the Bridge The wheel-house is located above the main deck (see Appendix B) and visibility is good in all directions. The windows are large and separated by thin vertical frame members to minimize obstruction to visibility. There is a 360 field of view from inside the wheel-house. The forward windows are angled so as to reduce the glare which can sometimes affect visibility. A T-shaped central integrated navigation console is located in the centre against the wheel-house forward bulkhead (see Appendix B). The workstation on the left side of the console has a radar screen and a number of switches and controls for vessel systems. The workstation on the right side of the console has a 61 cm radar screen fitted with an Automatic Radar Plotting Aid (ARPA) system, controls for the main engine and bow thruster, and a terminal to operate the ship's computers and alarms. The helmsman's workstation completes the layout of the wheel-house and bridge. 1.14 Navigation Equipment 1.14.1 Vessel The navigation instruments were in working order and no anomalies were reported. 1.14.2 Navigational Aids At that time of the year (early spring), light buoys C65, C67 and C68 are not in place. However, the unlighted winter spar buoys were in their charted positions. 1.15 Laviolette Bridge The Canadian Hydrographic Service publication, Sailing Directions, describes the Laviolette bridge as follows: Pont Laviolette crosses the St. Lawrence River about 0.6 mile downstream of Pointe des Ormes. It has a vertical clearance of 50 m (164 ft) under the main span, 335 m (1 100 ft) in length. The bridge is well marked with lights. Two Racons are located on the Pont Laviolette; the north Racon () and the south Racon (). Seen from downstream, the Laviolette bridge is marked by a series of seven lights mounted below the bridge span. These lights are red, green or white in colour. The green lights mark the mid-points of the main span and of the first two spans to the north. Two red lights indicate the maximum width of the centre channel, that is, 225 m. The roadway is illuminated by street lamps along the full length of the bridge. The navigable width between the first two piers to the north of the channel is about 56 m, and minimum water depth is 11.8 m (see Appendix A). 1.16 Composition of the Bridge Watch The bridge watch comprised the master, the third officer, a helmsman and the pilot.